Everyone wants a textbook outcome

Textbook outcome has been proposed as a combined endpoint after major surgery. Although the textbook outcome definition varies according to the type of surgery, it usually includes: no mortality, no complication, no readmission, and usually a surrogate oncological parameter. This combination is thought to result in more composite outcomes, which might be more reflective of the quality of surgical care rather than single parameters. In addition, textbook outcome has been linked to improved long term survival.

The international multicentre study including 2179 patients from 137 centers in 41 countries by the Oesophago-Gastric Anastomotic Audit Collaborative highlights textbook outcome as an interesting and relevant parameter in oesophageal surgery. While morbidity and mortality was not correlated with centre volume, the study shows patients who had surgery in high volume centres more often have a textbook outcome. In addition, the presence of specialist oesophagogastric surgeons and radiology on-call was associated with textbook outcome. These findings strengthen the move to centralization of these complex surgical procedures, especially considering textbook outcome also seems to be correlated to long term survival.

The main issue with textbook outcome is the definition. While there will be no debate that patients who die or have major complications do not fit within textbook outcome definition, it can be argued that a minor complication may also have an effect. The true impact of many minor complications of Dindo grade I or even grade II have a variable effect on the postoperative course. These minor setbacks can also be considered ‘normal’  and not likely to impact longer term survival or quality of life. Hospital stay without morbidity for longer than 21 days, which is included [is this included or excluded from textbook outcome?] in the definition is another point of discussion. Although the number of patients admitted for more than 3 weeks after surgery without any complication is limited, the odds that this length of stay is associated with logistical, rather than clinical, issues is high and perhaps again less relevant in the longer term. The inclusion of at least 15 harvested lymph nodes is perhaps the most controversial factor included in the definition of textbook outcome. It is questionable whether any patient cares about the number of lymph nodes removed from their body. As discussed in the paper, the lymph node harvest is also in part linked to the effort put in at pathological examination: the more effort, the more lymph nodes will be identified. In itself, lymph node yield is a very indirect outcome. Of course, the yield is related to the accuracy of tumour staging, yet, there are few postoperative treatment consequences. In addition, the evidence that a greater number of harvested lymph nodes improves prognosis is yet to be presented.

Despite possible debate on the definitions, textbook outcome is an interesting measure, and the available data suggest it reflects the quality of care in a more comprehensive way than single outcome parameters. The extensive analyses performed in this international collaboration have many interesting aspects and the data fuel numerous questions that have yet to be answered. But with the results of this study, it is hard for anyone involved in oesophageal surgery to overlook textbook outcome as a relevant parameter.